Assessment

Diagnosis

Scientific Rationale It is the deficit in oxygen and carbon dioxide elimination at the alveolar capillary membrane due to accumulation of fluid in the pleural space.

Planning

Intervention

Scientific Rationale

Evaluation

Subjective data: Impaired gas Nahihirapan akong huminga as verbalized exchange related to fluid shifting by the patient in the pleural space secondary Objective data: to pulmonary >Respiratory rate of congestion. 35 bpm >Cyanosis >Use of accessory muscle >Crackles >Non-productive cough

GOALS: After 8 hours of nursing intervention, the patient will improve respiration OBJECTIVES: >To be able to decrease respiratory rate from 35 bpm to atleast 30 bpm by positioning the patient in semi fowler position and administration of oxygen inhalation. >To be able to change cyanosis to pinkish skin, lips and nail bed color by providing adequate oxygen for better circulation of blood.

INDEPENDENT
>Monitor vital sign.

>Monitor color of the skin, use of accessory muscle oxygen saturation, depth, pattern and rate of respiration.

>Position patient in semi fowler position.

>Secure oxygen at bedside.

>Minimize activities and energy expenditures. DEPENDENT >Give oxygen as prescribed by the physician .

>For baseline data and for further comparison. >This assessment data alert the health care provider to potential hypoxemia or hypercapnea. >To promote lung expansion and decreasing the work of breathing. >Oxygen support alveolar gas exchange and improve oxygen in blood and tissue. >Rest is vital to reduce oxygen and energy demand. >Oxygen support alveolar gas exchange and improve oxygen in blood and tissue.

Goal partially met. After 8 hours of nursing intervention the patient respiratory rate decrease from 35 bpm to 30 bpm but the skin, remain cyanosis.

>Give bronchodilator

as prescribed by the physician. COLLABORATIVE > Review laboratory and diagnostic results such as ECG, Chest xray, CBC, Blood chemistry

>It relaxes bronchial smooth muscle leading to brocho dilation. >To note any incongruence and alteration in the results.

Assessment

Diagnosis

Scientific Rationale

Planning

Intervention

Scientific Rationale

Evaluation

Subjective Data: Hindi ako masyado nagkikilos kasi ang bilis kong mapagod verbalized by the patient. Objective Date: >murmur >cold clammy skin >4 sec. Capillary refill >BP: 140/80 mmHg

Decrease cardiac output related to myocardial contractility.

The amount of blood pump by each ventricles during a given period, cardiac output must be responsive to changes in metabolic demands of the tissue.

Goal: After 8 hours of nursing intervention pt will lessen streessors that can help in reducing the workload of the heart participate in activities that reduce the work load of the heart like stress management, therapeutic medication, and balanced activity rest pattern. Objective: >To be able to promote blood circulation>To be able to demonstrate an increase in activity tolerance

Independent: >Monitor VS, note for cardiac rate and blood pressure.

>Keep client on bed, promote rest, semi fowler position is preferred and may elevate feet in shock situations. >Encourage slowly dangling of legs before standing. >Limit visitors.

>Provide baseline data for comparison to follow trends and evaluate response to intervention. >Decrease O2 consumption and promote venous return.

Goal partially met. After 8 hours of nursing intervention pt was able to participate in activities that reduced the workload of the heart.

>Encourage relaxation techniques such as deep breathing exercises. Dependent: >Administer O2 .

>To prevent orthostatic hypotension >To promote adequate rest and sleep. >To reduce anxiety.

>To increase O2 available for cardiac function and for tissue perfusion.

Collaborative: >Collaborate with the dietician to adjust ind. Diet plan such as Low Salt Low Fat, bland diet with frequent small feeding. >Discuss sign and symptoms that require prompt reporting to health care provider (muscle cramps, headache and dizziness.

>To maintain adequate nutrition balance.

>Immediate consultation because this could be sign of drug toxicity and mineral losses.

Assessment

Diagnosis

Scientific Rationale

Planning

Intervention

Scientific Rationale

Evaluation

Subjective Data: Nag manas yung paa ko verbalized by the patient Objective Data: >Edema

Excess fluid volume related to increased ADH production and sodium/water retention

It is refers to an isotonic expansion caused by abnormal retention of water and sodium. This may be related to simple fluid overload or diminished function of homeostatic mechanism responsive for regulating fluid balance.

Goal: After 8hrs of nursing intervention the patient will be able to reduce recurrence of fluid excess.

Independent: >Monitor VS.

>Note presence of underlying condition that potential fluid excess Objective: >Note presence >To be able to reduce of edema and accumulation calculate its grade of fluid (edema) >Note pattern on feet and of urination different part of the body. >Elevate edema to us part (feet) and change position frequently

>Establish baseline data for further comparison >To assess precipitating factor >To evaluate degree of edema

Goal partially met after 8 hrs of nursing intervention, patient was able to reduce recurrence of fluid excess and decreased edema.

>To know if there is fluid retention in the body >To reduce tissue pressure and decrease risk of skin breakdown >Measure I and O >To measure intake of fluids accurately >Promote ambulation >To promote circulation and to mobilize excess fluid

Dependent: >Restrict Na and

Fluid as indicated >Administer diuretics as prescribed Collaborative: >Assist with procedure as indicated (paracentesis)